- Home
- Non 12-Step Information for Professionals
- Theories of Addiction
- Dual Diagnosis
- Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders
Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders
- By N.I. D.A.
- Published 01/15/2007
- Dual Diagnosis
- Unrated
Depression, Substance Use, and Sexual Orientation as Cofactors in HIV-1 Infected Men: Cross-Cultural Comparisons
Paul Satz, Hector F. Myers, Mario Maj, Fawzy Fawzy, David L. Forney, Eric G. Bing, Mark A. Richardson, and Robert Janssen
INTRODUCTION
The co-occurrence of major depression in medical populations has been the subject of much controversy in the past decade.
Although some investigators have suggested that reports of an increased prevalence of depression may, in part, be due to misclassification based on physician reliance on self-report methods (Perez-Stable et al. 1990) or on failure to adjust for symptoms induced by physical illness (Plumb and Holland 1977), most studies have suggested that the prevalence of depression is high, although often undetected by the primary care physician (Perez-Stable et al. 1990; Schulberg et al. 1985).
Schulberg and colleagues (1985) state that it is unclear whether this oversight reflects true limitations in the physician's diagnostic acumen, his/her lack of concern for social implications, or whether it is an artifact of existing classification procedures.
Regardless of the reasons for its underreporting, the detection and treatment of depression is crucial, especially for medically ill patients, because depressive disorders may adversely affect survival, length of hospital stay, compliance with therapy, ability to care for oneself, and quality of life (Schulberg et al. 1985).
These concerns are particularly relevant to human immunodeficiency virus type 1 (HIV-1), where the co-occurrence of major depression has received only limited recent attention. Based on initial reports using chart reviews (Perry and Tross 1984), it has been suggested that over 83 percent of hospitalized acquired immunodeficiency syndrome (AIDS) patients have significant disturbances in mood.
Unfortunately, anecdotal studies such as this fail to use structured diagnostic interviews to distinguish transitory dysphoria in response to the clinical condition and its treatment from syndromal depression. The latter disorder is more serious and merits direct clinical intervention because it may be predictive of more accelerated course and early mortality.
In addition, such reporters do not investigate 131 other cofactors that could account for the co-occurrence of depression in HIV-1 disease. The purpose of this chapter, therefore, is to examine the evidence of the co-occurrence of major depression in persons infected with HIV- 1, with special attention to the potential role that cofactors such as substance use and sexual orientation (i.e., being gay or bisexual) might play in accounting for the association.
The chapter is organized into two parts. Part I presents a brief summary of the literature on syndromal depression in HIV-1 that was part of a larger review on the assessment of mood disorder in medical populations (Satz et al., in press).
Part II presents a reanalysis of data from two large recent cohort studies of HIV-1 in populations in the United States and abroad, the World Health Organization (WHO) Multicentre Study of HIV-1 (Maj et al. 1994a, 1994b). The latter provides a more direct test of the relationship of syndromal depression in HIV-1, with special focus on substance use and sexual orientation as important cofactors.
PART I Syndromal Depression and HIV-1 (Summary Review)
There are eight studies in the literature that report the prevalence of current and/or lifetime major depression in HIV-infected adults. Each study used structured diagnostic interview instruments and Diagnostic and Statistical Manual of Mental Disorders, 3d ed. revised (DSM-IIIR), or ICD-10 criteria to define syndromal disorder.
The results from these studies, which are summarized in table 1, indicate two general findings. The first is that none of the studies found an association of HIV-1 with lifetime depression, and only one found an association with current (1 month) depression (Baldeweg et al. 1993).
In addition, none of the studies reported an association between either lifetime or current depression and early (presymptomatic) HIV-1 infection. The second finding is that, despite the general lack of association between major depressive disorders (MDD) and HIV-1, the rates for both current and lifetime depression in HIV-infected persons were significantly higher than the prevalence rates for depression in the general population reported in both the Epidemiologic Catchment Area (ECA) study (Regier et al. 1988) and in the more recent National Comorbidity Survey (NCS) (Kessler et al. 1994).
The average prevalence rates for lifetime MDD in HIV seropositive men (23.7 percent) was approximately fivefold higher than the average rate reported for men in the ECA (4.6 percent) and 1.8 times higher than reported for men in the NCS (13 percent).
With respect to current depression, the observed rates were approximately 3.8 times higher than reported for 1-month ECA rates for men (2.3 percent). NCS rates for current major depression were available only for the past 12 months. Comparisons are presented for men only because the studies of HIV-1 included primarily well-educated, white, gay, male volunteers, which reflects the population most affected in the first wave of the disease.
For example, in five of the studies the participants were described as gay or bisexual (Tross et al. 1987; Atkinson et al. 1988; Williams et al. 1991; Baldeweg et al. 1993; Perkins et al., in press). Given the population trends for this disease, it is very likely that the majority of the participants in these early studies were gay or bisexual.
Despite the generally null findings regarding the association between MDD and HIV-1, one must note that few studies contrasted the spectrum of HIV-1 infection (Tross et al. 1987; Atkinson et al. 1988; Baldeweg 1993), while other studies pooled cases of presymptomatic and sympto- matic HIV-1 infection (Perry 1990; Pace et al. 1990).
The pooling of early stage and advanced stage patients could attenuate the HIV-MDD association if the latter is more likely to be present in advanced cases. Also, most studies had small sample sizes, which restricts power to detect an association between these putative comorbid outcomes.
The consistently high rates of MDD across studies, regardless of serostatus, raises the question of whether sexual orientation or other factors may be unexamined independent risk factors for major depression.
Only one study (Atkinson et al. 1988) explored this hypothesis by including two small samples of noninfected gay (N = 11) and heterosexual (N = 22) controls. This study was the first to show an elevated rate of MDD in the gay and bisexual groups, independent of serostatus, suggesting that sexual orientation and lifestyle may be risk factors for major depression.
It is also noteworthy that despite evidence of significant substance abuse among those at highest risk for HIV-1 infection (Donahoe 1990; Parker and Carballo 1992), none of these studies investigated whether the increased prevalence of depression in their samples may have been attributable, either directly or indirectly, to the widespread abuse of alcohol and other substances.
~~~
Continued on source document:
NIDA Research Monograph, Number 172
Paul Satz, Hector F. Myers, Mario Maj, Fawzy Fawzy, David L. Forney, Eric G. Bing, Mark A. Richardson, and Robert Janssen
INTRODUCTION
The co-occurrence of major depression in medical populations has been the subject of much controversy in the past decade.
Although some investigators have suggested that reports of an increased prevalence of depression may, in part, be due to misclassification based on physician reliance on self-report methods (Perez-Stable et al. 1990) or on failure to adjust for symptoms induced by physical illness (Plumb and Holland 1977), most studies have suggested that the prevalence of depression is high, although often undetected by the primary care physician (Perez-Stable et al. 1990; Schulberg et al. 1985).
Schulberg and colleagues (1985) state that it is unclear whether this oversight reflects true limitations in the physician's diagnostic acumen, his/her lack of concern for social implications, or whether it is an artifact of existing classification procedures.
Regardless of the reasons for its underreporting, the detection and treatment of depression is crucial, especially for medically ill patients, because depressive disorders may adversely affect survival, length of hospital stay, compliance with therapy, ability to care for oneself, and quality of life (Schulberg et al. 1985).
These concerns are particularly relevant to human immunodeficiency virus type 1 (HIV-1), where the co-occurrence of major depression has received only limited recent attention. Based on initial reports using chart reviews (Perry and Tross 1984), it has been suggested that over 83 percent of hospitalized acquired immunodeficiency syndrome (AIDS) patients have significant disturbances in mood.
Unfortunately, anecdotal studies such as this fail to use structured diagnostic interviews to distinguish transitory dysphoria in response to the clinical condition and its treatment from syndromal depression. The latter disorder is more serious and merits direct clinical intervention because it may be predictive of more accelerated course and early mortality.
In addition, such reporters do not investigate 131 other cofactors that could account for the co-occurrence of depression in HIV-1 disease. The purpose of this chapter, therefore, is to examine the evidence of the co-occurrence of major depression in persons infected with HIV- 1, with special attention to the potential role that cofactors such as substance use and sexual orientation (i.e., being gay or bisexual) might play in accounting for the association.
The chapter is organized into two parts. Part I presents a brief summary of the literature on syndromal depression in HIV-1 that was part of a larger review on the assessment of mood disorder in medical populations (Satz et al., in press).
Part II presents a reanalysis of data from two large recent cohort studies of HIV-1 in populations in the United States and abroad, the World Health Organization (WHO) Multicentre Study of HIV-1 (Maj et al. 1994a, 1994b). The latter provides a more direct test of the relationship of syndromal depression in HIV-1, with special focus on substance use and sexual orientation as important cofactors.
PART I Syndromal Depression and HIV-1 (Summary Review)
There are eight studies in the literature that report the prevalence of current and/or lifetime major depression in HIV-infected adults. Each study used structured diagnostic interview instruments and Diagnostic and Statistical Manual of Mental Disorders, 3d ed. revised (DSM-IIIR), or ICD-10 criteria to define syndromal disorder.
The results from these studies, which are summarized in table 1, indicate two general findings. The first is that none of the studies found an association of HIV-1 with lifetime depression, and only one found an association with current (1 month) depression (Baldeweg et al. 1993).
In addition, none of the studies reported an association between either lifetime or current depression and early (presymptomatic) HIV-1 infection. The second finding is that, despite the general lack of association between major depressive disorders (MDD) and HIV-1, the rates for both current and lifetime depression in HIV-infected persons were significantly higher than the prevalence rates for depression in the general population reported in both the Epidemiologic Catchment Area (ECA) study (Regier et al. 1988) and in the more recent National Comorbidity Survey (NCS) (Kessler et al. 1994).
The average prevalence rates for lifetime MDD in HIV seropositive men (23.7 percent) was approximately fivefold higher than the average rate reported for men in the ECA (4.6 percent) and 1.8 times higher than reported for men in the NCS (13 percent).
With respect to current depression, the observed rates were approximately 3.8 times higher than reported for 1-month ECA rates for men (2.3 percent). NCS rates for current major depression were available only for the past 12 months. Comparisons are presented for men only because the studies of HIV-1 included primarily well-educated, white, gay, male volunteers, which reflects the population most affected in the first wave of the disease.
For example, in five of the studies the participants were described as gay or bisexual (Tross et al. 1987; Atkinson et al. 1988; Williams et al. 1991; Baldeweg et al. 1993; Perkins et al., in press). Given the population trends for this disease, it is very likely that the majority of the participants in these early studies were gay or bisexual.
Despite the generally null findings regarding the association between MDD and HIV-1, one must note that few studies contrasted the spectrum of HIV-1 infection (Tross et al. 1987; Atkinson et al. 1988; Baldeweg 1993), while other studies pooled cases of presymptomatic and sympto- matic HIV-1 infection (Perry 1990; Pace et al. 1990).
The pooling of early stage and advanced stage patients could attenuate the HIV-MDD association if the latter is more likely to be present in advanced cases. Also, most studies had small sample sizes, which restricts power to detect an association between these putative comorbid outcomes.
The consistently high rates of MDD across studies, regardless of serostatus, raises the question of whether sexual orientation or other factors may be unexamined independent risk factors for major depression.
Only one study (Atkinson et al. 1988) explored this hypothesis by including two small samples of noninfected gay (N = 11) and heterosexual (N = 22) controls. This study was the first to show an elevated rate of MDD in the gay and bisexual groups, independent of serostatus, suggesting that sexual orientation and lifestyle may be risk factors for major depression.
It is also noteworthy that despite evidence of significant substance abuse among those at highest risk for HIV-1 infection (Donahoe 1990; Parker and Carballo 1992), none of these studies investigated whether the increased prevalence of depression in their samples may have been attributable, either directly or indirectly, to the widespread abuse of alcohol and other substances.
~~~
Continued on source document:
NIDA Research Monograph, Number 172
